CERTIFICATE OF LIABILITY INSURANCE

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1 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, ETEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Insurance Agent/Broker INSURED Subcontractor CONTACT NAME: PHONE (A/C, No, Ext): ADDRESS: PRODUCER CUSTOMER ID #: FA (A/C, No): INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Insurance Companies Insurance Co INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ECLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS EACH OCCURRENCE 1,000, DAMAGE TO RENTED PREMISES (Ea occurrence) 50,000 CLAIMS-MADE OCCUR MED EP (Any one person) 5, A PERSONAL & ADV INJURY 1,000, GENERAL AGGREGATE 2,000, GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 2,000, POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 1,000, ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS BODILY INJURY (Per accident) B D AUTOS HIRED AUTOS NON-OWNED AUTOS Certificate Contact at Producer's Office PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EACH OCCURRENCE OCCUR ECESS LIAB C CLAIMS-MADE AGGREGATE 3,000, DEDUCTIBLE ISSUE DATE RETENTION WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y / N ANY PROPRIETOR/PARTNER/EECUTIVE E.L. EACH ACCIDENT D OFFICER/MEMBER ECLUDED? N / A 100,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE 100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 500,000 3,000, DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Job Number and Project Name Additional insured with respect to General Liability, Auto Liability, Pollution Liability, Professional Liability and Excess/Umbrella Liability on a primary & noncontributory basis when required by written contract: (LIST OF ADDITIONAL INSUREDS). Waiver of subrogation in favor of the listed additional insured with respect to General Liability, Auto Liability, Pollution Liability, Professional Liability and Workers Compensation policies. Additional insured with respect to General Liability coverage per ISO forms CG2010 and CG2037 edition 10/01 or CG /85. CERTIFICATE HOLDER CANCELLATION W.D.S. Construction, Inc. 111 Rowell St. Beaver Dam, WI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Signature of Agent/Broker ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered

2 CG CONTRACTORS D PERSON OR ORGANIZATION COVERAGE PART Name of Person or Organization: -Any person or organization required by written contract or agreement (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or CG ISO Properties, Inc., 2000

3 CG THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS COMPLETED OPERATIONS COVERAGE PART Name of Person or Organization: Any Person or organization with whom you have agreed, through written contract, agreement or permit, executed prior to the loss, to provide additional insured coverage for completed operations Location And Description of Completed Operations: Any location where you have agreed through written contract, agreement or permit, executed prior to the loss, to provide additional insured coverage for completed operations Additional Premium: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) CG ISO Properties, Inc., 2000

4 CG Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations Any Person or organization with whom you have agreed, through Any location agreed where you through have written agreed contract, through written contract, agreement or permit, executed prior to the loss, to written agreement contract, or permit, agreement to provide or permit, additional executed insured prior provide additional insured coverage for ongoing completed operations to coverage the loss, for to completed provide additional operations insured coverage for ongoing operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insured s, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG ISO Properties, Inc., 2004

5 GLO CG THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS COMPLETED OPERATIONS COVERAGE PART Name Of Additional Insured Person(s) Location And Description Of Completed Or Organization(s): Operations Any Person or organization with whom you have agreed, Any location where you have agreed through written contract, through written contract, agreement or permit, executed prior to agreement or permit, executed prior to the loss, to provide the loss, to provide additional insured coverage for completed additional insured coverage for completed operations operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG ISO Properties, Inc., 2004

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